What is the recommended treatment for cystitis?

Management of Cystitis

For uncomplicated cystitis, first-line treatment is trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) in regions where local E. coli resistance is below 20%, nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days), or fosfomycin trometamol (3 g single dose). 1

Diagnostic Approach

• Diagnosis is primarily clinical based on:
  • Frequency and dysuria
  • Normal physical exam or suprapubic tenderness
• Urinalysis is recommended, but routine urine culture is not necessary for uncomplicated cases 2
• Obtain urine culture before treatment in:
  • Suspected pyelonephritis
  • Symptoms that persist or recur within 2-4 weeks after treatment
  • Atypical presentations 2

Treatment Algorithm

First-Line Options for Uncomplicated Cystitis

1. Trimethoprim-sulfamethoxazole (TMP-SMX)

   • Dosage: 160/800 mg (double-strength tablet) twice daily
   • Duration: 3 days
   • Considerations: Use only when local E. coli resistance is <20% and patient has no history of recent TMP-SMX use or international travel 1, 3

2. Nitrofurantoin monohydrate/macrocrystals

   • Dosage: 100 mg twice daily
   • Duration: 5 days
   • Considerations: Avoid in patients with renal impairment (GFR <30 ml/min) and in third trimester of pregnancy 1

3. Fosfomycin trometamol

   • Dosage: 3 g
   • Duration: Single dose
   • Considerations: Slightly lower cure rates (75-85%) compared to other regimens 4

Alternative Options

• Trimethoprim alone
  • Dosage: 100 mg twice daily
  • Duration: 3 days 1

Special Populations

Pregnant Women

• Nitrofurantoin 100 mg twice daily for 5-7 days (avoid in third trimester)
• Avoid TMP-SMX in first trimester (risk of birth defects) and third trimester (risk of kernicterus) 1

Diabetic Patients

• Similar treatment approach as non-diabetic women
• Ensure good glycemic control during treatment 1

Patients with Renal Impairment

• Avoid nitrofurantoin if GFR <30 ml/min
• Adjust dosage for TMP-SMX in severe renal impairment 1

Hemodialysis Patients

• TMP-SMX at half the standard dose (one single-strength tablet daily or one double-strength tablet three times weekly) after each dialysis session 1

Treatment Duration

• Uncomplicated cystitis: 3-5 days (depending on antibiotic)
• Complicated cystitis: 5-7 days
• Pyelonephritis: 10-14 days 1

Follow-up

• Evaluate clinical response within 48-72 hours of initiating therapy
• No routine follow-up urine culture needed in patients who respond to therapy
• Consider follow-up urine culture 7 days after completing treatment in:
  • Persistent symptoms
  • Recurrent infections
  • Complicated cases 1

Prevention Strategies

• Antibiotic prophylaxis options:

  • Nitrofurantoin 50-100 mg daily
  • Trimethoprim 100 mg daily
  • Post-coital single dose when UTIs are related to sexual activity 1

• Non-antibiotic alternatives:

  • Methenamine hippurate (1 g twice daily)
  • Cranberry products containing 36 mg proanthocyanidin
  • Increased water intake (additional 1.5L daily)
  • Urinating after sexual activity 1

Common Pitfalls and Caveats

1. Antibiotic Resistance: Local resistance patterns significantly impact treatment success. TMP-SMX should be avoided in areas with >20% resistance rates 1, 5

2. Overtreatment: Treating asymptomatic bacteriuria increases antibiotic resistance without clinical benefit 1

3. Prolonged Treatment: Extended courses increase side effect risk and resistance without improving outcomes 1

4. Beta-lactams: Amoxicillin/clavulanate, cefaclor, cefdinir, and cefpodoxime are not recommended for initial treatment due to resistance concerns 2

5. Fluoroquinolones: Despite effectiveness, should be reserved for more invasive infections to prevent resistance development 6

6. Adverse Effects: Monitor for side effects, particularly with TMP-SMX (hyperkalemia, increased serum creatinine, acute kidney injury, and bone marrow suppression) 1

The evidence consistently supports short-course therapy for uncomplicated cystitis, with treatment choice guided by local resistance patterns. Immediate antimicrobial therapy is recommended over delayed treatment or symptom management alone 6.